NURS 230A-Fundamentals practice B
Final Exam Fully Solved.
A nurse is caring for a client who asks about the purpose of advance directives. Which of the
following statements should the nurse make? - Answer They indicate the form of treatment a
client is willing to accept in the event of a serious illness.
A nurse is caring for a client who has recently started using a behind-the-ear hearing aid. Which
of the following statements should the nurse identify as an indication that the client
understands the use of this assistive device? - Answer I will be sure to remove my hearing aid
before taking a shower.
A nurse is evaluating a client's use of a cane. Which of the following actions should the nurse
identify as an indication of correct use? - Answer The client holds the cane on the stronger
side of their body.
Rationale: The client should hold the cane on the stronger side of their body to increase support
and maintain alignment.
A nurse is caring for a group of clients. Which of the following actions should the nurse take to
prevent the spread of infection? - Answer Place a client who has tuberculosis in a room with
negative-pressure airflow.
Rationale: A client who has TB requires airborne precautions, which include placing the client in
a room that has negative-pressure airflow to reduce the risk of infection transmission.
A nurse is administering an otic medication to an older adult client. Which of the following
actions should the nurse take to ensure that the medication reaches the inner ear? - Answer
Pressing gently on the tragus of the ear will help the medication get into the inner ear.
A nurse is assessing an older adult client's risk for falls. Which of the following assessments
should the nurse use to identify the client's safety needs. (SATA) - Answer Pupil clarity
Visual fields
Visual acuity
A nurse is caring for a client who has decreased mobility. Which of the following actions should
the nurse take to decrease the client's risk of developing plantar flexion contractures? - Answer
Apply an ankle-foot orthotic device to the client's feet.
, Rationale: The nurse should use a device to maintain dorsiflexion, such as an ankle-foot orthotic
device or a foot board placed perpendicular to the mattress.
A nurse in a clinic is caring for a middle adult who states, "The doctor says that, since I am at an
average risk for colon cancer, I should have a routine screening. What does that involve?" Which
of the following responses should the nurse make? - Answer "You should have a fecal occult
blood test every year."
Rationale: Colorectal cancer screening for clients who are at average risk begins at age 45. One
option for screening is a fecal occult blood test annually.
A nurse is teaching an older adult client who is at risk for osteoporosis about beginning a
program of regular physical activity. Which of the following types of activity should the nurse
recommend? - Answer Walking briskly
Rationale: Weight-bearing exercises are essential for maintaining bone mass, which helps to
prevent osteoporosis. Walking engages older adult clients in this preventive and therapeutic
strategy.
A home health nurse is completing an admission assessment of an older adult client who has
their caregiver present. Which of the following findings should the nurse identify as a potential
indication of elder abuse? - Answer The caregiver insists on remaining in the room.
Rationale: A caregiver who refuses to leave the room during an assessment can be an indication
of potential mistreatment of the client who is receiving care. The nurse should evaluate the
client for additional signs of potential mistreatment throughout the admission assessment.
A nurse is performing a skin assessment for a client who expresses concern about skin cancer.
Which of the following findings should the nurse identify as a potential indication of a skin
malignancy? - Answer A mole with an asymmetrical appearance
Rationale: An uneven or asymmetrical shape is a potential indication of a skin malignancy. This
is manifested when part of a lesion or mole looks different from the other part.
A nurse is teaching a client and their family how to care for client's trach at home. Which of the
following instructions should the nurse include in the teaching? - Answer Use tracheostomy
covers when outdoors.
Rationale: Tracheostomy covers protect the client's airway from cold air, dust, and other
airborne particles.
Final Exam Fully Solved.
A nurse is caring for a client who asks about the purpose of advance directives. Which of the
following statements should the nurse make? - Answer They indicate the form of treatment a
client is willing to accept in the event of a serious illness.
A nurse is caring for a client who has recently started using a behind-the-ear hearing aid. Which
of the following statements should the nurse identify as an indication that the client
understands the use of this assistive device? - Answer I will be sure to remove my hearing aid
before taking a shower.
A nurse is evaluating a client's use of a cane. Which of the following actions should the nurse
identify as an indication of correct use? - Answer The client holds the cane on the stronger
side of their body.
Rationale: The client should hold the cane on the stronger side of their body to increase support
and maintain alignment.
A nurse is caring for a group of clients. Which of the following actions should the nurse take to
prevent the spread of infection? - Answer Place a client who has tuberculosis in a room with
negative-pressure airflow.
Rationale: A client who has TB requires airborne precautions, which include placing the client in
a room that has negative-pressure airflow to reduce the risk of infection transmission.
A nurse is administering an otic medication to an older adult client. Which of the following
actions should the nurse take to ensure that the medication reaches the inner ear? - Answer
Pressing gently on the tragus of the ear will help the medication get into the inner ear.
A nurse is assessing an older adult client's risk for falls. Which of the following assessments
should the nurse use to identify the client's safety needs. (SATA) - Answer Pupil clarity
Visual fields
Visual acuity
A nurse is caring for a client who has decreased mobility. Which of the following actions should
the nurse take to decrease the client's risk of developing plantar flexion contractures? - Answer
Apply an ankle-foot orthotic device to the client's feet.
, Rationale: The nurse should use a device to maintain dorsiflexion, such as an ankle-foot orthotic
device or a foot board placed perpendicular to the mattress.
A nurse in a clinic is caring for a middle adult who states, "The doctor says that, since I am at an
average risk for colon cancer, I should have a routine screening. What does that involve?" Which
of the following responses should the nurse make? - Answer "You should have a fecal occult
blood test every year."
Rationale: Colorectal cancer screening for clients who are at average risk begins at age 45. One
option for screening is a fecal occult blood test annually.
A nurse is teaching an older adult client who is at risk for osteoporosis about beginning a
program of regular physical activity. Which of the following types of activity should the nurse
recommend? - Answer Walking briskly
Rationale: Weight-bearing exercises are essential for maintaining bone mass, which helps to
prevent osteoporosis. Walking engages older adult clients in this preventive and therapeutic
strategy.
A home health nurse is completing an admission assessment of an older adult client who has
their caregiver present. Which of the following findings should the nurse identify as a potential
indication of elder abuse? - Answer The caregiver insists on remaining in the room.
Rationale: A caregiver who refuses to leave the room during an assessment can be an indication
of potential mistreatment of the client who is receiving care. The nurse should evaluate the
client for additional signs of potential mistreatment throughout the admission assessment.
A nurse is performing a skin assessment for a client who expresses concern about skin cancer.
Which of the following findings should the nurse identify as a potential indication of a skin
malignancy? - Answer A mole with an asymmetrical appearance
Rationale: An uneven or asymmetrical shape is a potential indication of a skin malignancy. This
is manifested when part of a lesion or mole looks different from the other part.
A nurse is teaching a client and their family how to care for client's trach at home. Which of the
following instructions should the nurse include in the teaching? - Answer Use tracheostomy
covers when outdoors.
Rationale: Tracheostomy covers protect the client's airway from cold air, dust, and other
airborne particles.
